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Maxillofacial Prosthetics

Its concerns the restoration and/or replacement of remaining teeth and associated oral and facial structures
with artificial substitutes.
Types of maxillofacial defects
Congenital defects Acquired defects Developmental defects
Cleft palate, cleft lip, missing ear and Due to surgery, disease or traumatic Prognathism, retrognathism,
facial cleft. accidents. micrognathia and macrognathia.

Classification of maxillofacial prosthesis


Intra –oral prostheses
Name Definition and function Examples
A- Obturators Close congenital or acquired defects Defects of the palate
B- Stents Control bleeding, promote healing vehicle Anti-hemorrhagic stents,
for radiation therapy, hold grafts in place mouth protectors, radium
carriers and applicator.
C- Splints To hold fractured fragments together until
healing occurs
D- Resection Appliance In case of mandibular fracture to correct
the path of closure of resected mandible
Extra-oral Prosthesis
A- Radium Shield Protection from radiation.
B- Restoration of missing Missing eyes, nose or ear with prosthetic eye, nose or ear.
C- Ear plugs Hearing aids
Combination of intra and extra oral prostheses
Used in case partial loss of the maxilla or mandible that includes facial structures.

Cranial and facial Prosthesis


A- Cranial onlays and inlays Used in cranioplasty  compensate for cranial bone loss due
to skull injury.
B- Intra mandibular implants Used to support or retain a restoration replacing a missing part
of the mandibular bone.

Maxillofacial Team
1- Surgeon: Repair and surgical reconstruction of deformities.
2- Prosthodontist: when artificial restoration is the only way in rehabilitation of maxillofacial patients.
3- Orthodontist: treating malocclusion associated with cleft lip and/or platate.
4- Otolaryngologist (ENT): Assist in evaluation and management of ear infection or hearing loss.
5- Audiologist (hearing specialist): professional who assist and manages any hearing difficulties.
6- Psychologist: helps the patient to accept his problem, raise his moral and psychological attitude and to gain
patient’s co-operation during treatment.
7- Pediatrician: To follow the child as he grows and coordinate the multiple specialists involved.
8- Pediatric dentist: to evaluate and care for child’s teeth.
9- Speech Therapist: to correct the defective speech due to palatal defects. Most valuable in congenital cleft cases.
10- Nurse: experienced pediatric nurse and link between the family and the Team
11- Genetic Counselor: professional who reviews medical and family history to help in diangosis. Also counselor
regarding possible risk of recurrence in future pregnancy.
12- Social worker: discus the problem with parents, educate parent and patient, guidance for future life after treatment.
13- Dental technician: very important role in constructing a successful and accurate appliance needed for the case.

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Congenital defects of the lip and palate
|Definition| the lack of fusion between the embryological processes which would normally unite to form the
lip and palate during the inter-uterine, it appears as a discontinuity of the roof of the mouth (either whole or
partial) in the form of a fissure called cleft palate.

|Incidences|
- One in every 800 born infants.
- Unilateral clefts are more common than bilateral.
- Left side more than right side.
- Males twice than femals.

|Anatomy|
- Maxilla:
o Pyramidal shaped bone.
o Has a body forming the midface.
o Has four processes:
 Frontal Process: directed upwards
 Zygomatic Process: directed upwards
 Alveolar Process: directed downwards  carries the teeth.
 Palatine Process: directed downwards  2/3 posterior of the hard palate.
- Hard Palate:
o Composed of the maxillary and palatine bone plates.
 2/3 anterior by the palatine process from the maxillary bone.
 1/3 posterior by the horizontal maxillary plate of the palatine bone.
o Divided by the midline suture.
o Anterior portion of the palate is formed of anterior portion of the alveolar process (carrying the anterior
teeth and pre-maxilla).
o Nerve supply anteriorly from the incisive foramina and lateral-posteriorly from the greater and lesser
palatine foramen.
- Soft palate:
o It’s attached to the posterior rim of the hard palate.
o It’s not ossified portion of the palate, it consists of series muscles and dense elastic fibers.
o The soft palate and with pharynx forms a sphincter that opens and close the orifice between the nasal
cavity (superiorly) and oro-pharyngeal cavity (inferiorly)
o Medially there is the uvula (which is attached to the velum) a posterior and downward extension.
 It acts as a valve for the pharyngeal cavity.
- Palato (velo) Pharyngeal Sphincter:
o It’s important for proper swallowing, deglutition and speech.
o During closure  important for swallowing and pronunciation of most letters except nasal sounds (M).
o During Swallowing  it closes to prevent food entering the naso-pharynx.
o During Speech  it closes to allow air to go though the oral cavity to produce noise.
o The valve is coordinated by the muscles of the soft palate and pharynx.

Muscles of the palate Muscles of the pharynx


Levator veli palatini muscle (most important) Palato glossus muscle Superior constrictor muscle.
Tensor Veli palatine muscle. Palate pharynges muscle Salpingo pharynges muscle.
Uvula muscle (intrinsic muscle of the velum)
Long muscle that provides a wide range of movements to move the velum
from the relaxed rest position to a fully elevated position.
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|VIP| What is the Plato-pharyngeal mechanism?
The Velum has three positions:

- Relaxed position of the velum:


o Required for normal breathing from both the oral and nasal pathway.
o The velum is dropped downwards to keep the naso-pharynx and oro-pharynx opened.

- Closures of the oral cavity:


o Required to permit the exit of air through the nasal cavity for nasal breathing.
o Required during sucking.
o Required for pronunciation of sounds “M” and “Ng”
o Mechanism:
 Palato pharynges muscles pull the soft palate down towards the tongue.
 Tensore veli palatine muscles flattens the dome shaped of the soft palate.
 Palato glossus muscles contracts to force the tongue upward and backward.

- Closure of the nasal cavity:


o Required for swallowing and pronunciation of the letters in the oral cavity.
o Mechanism:
 Middle 1/3 of the velum is curved upwards and backwards contacting the posterior wall of the
pharynx.
 It contacts at or above the plane of the plate at the level of the atlas vertebra.
 Done by Levator veli palatine muscle.
 Aided by the uvulae muscle to add bulk to the nasal surface of the velum.
 The closure isn’t completely done by the velum alone but the pharynx also accommodates by:
 Forward movement of the posterior wall of the pharynx (by the superior constrictor muscle and
aided by the palate pharynges muscle).
 Lateral movement of the medially walls of the pharynx (by the Salpingo pharynges muscle)
 Strong Contraction of the posterior pharyngeal muscles to produce a prominent ridge called
“Ridge of Passavant” which helps to approximate the soft palate with the pharynx.

o Ridge of passavant:
 Is a horizontal roll of tissue on the posterior wall of the pharynx forming prominence on the
posterior wall of the pharynx, its located at the level of the plate (at the level of the atlas vertebra).
 More prominent in cases of soft palate defects with a compensating mechanism.
 A guide for placement of prophesies restoring palatal defects.

|Plato pharyngeal insufficiency | |Plato pharyngeal incompetence |


Causes  Inadequate, short length of the soft palate Causes  normal tissue is present but with impaired
(due to congenital or developmental defects) leading function (due to neurologic disease “poliomyelitis” or
to inadequate palate pharyngeal closure. cerebro vascular accidents) leading to inadequate
palate pharyngeal closure.
TTT  palatal lift prostheses.

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|Embryology|

- Primary palate, secondary plate and nasal septum fuse  forming the lip, maxilla and hard palate.
- Union between the processes begins at the meeting point of the primary plate and the two lateral palatine
processes.
- From this point union continues in to direction:
o Anteriorly  pre-maxilla, upper anterior ridge and lip.
o Posterior  hard palate and soft palate.

|Cleft Lip| “hare lip”

- Due to union failure between the pre-maxillary process and the two lateral processes on each side.
- Various extension between a simple Notch of the lower boarder of the upper lip on one side to complete
bilateral cleft of the lip (hare lip) leading to a middle segment of the lip (Prolabriun) to be only attached to
the nasal septum.

|cleft Palate|

- Failure of union between the primary palate and the lateral palatine process.
- Classification:  Veau’s classification
o Class I  cleft including the soft palate only.
o Class II  cleft including the soft and hard palate till the incisive foramen
o Class III  cleft on both (hard and soft) plate unilaterally till the alveolar ridge and upper lip.
o Class IV  cleft on both (hard and soft) plate bilaterally till the alveolar ridge and upper lip.

|Etiology and factors causing formation of clefts|

- Main: Changes in the embryo position, Changes in the pressure of the aminiotic fluid, Persistence of
epithelium at the junction of the inferring with the process fusion.
- Hereditary Factors: it’s greater if the parents had deformities.
- Infection or disease: During pregnancy  German measles
- Diet deficiency: Deficiency may induce cleft formation  Vit.A and riboflavin deficiency.
- Chemical irritation: Exposure of the mother to chemical irritants during pregnancy may induce cleft
formation  Hypoxia or hyper vitaminosis.
- Radiation: Exposure of mother to X-ray or therapeutic radiation of the pelvis during pregnancy.
- Hormonal disturbance or cortisone may influence cleft formation.
- Physiological: Stress, anxiety during the first trimester may induce cleft formation.

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|Disabilities Associated with cleft lip and palate|
1- Improper nutrition:
 Cleft palate:
o Cannot suck  absence of negative pressure in oral cavity. Malnutrition and
o Food Escape through the nasal cavity. debilitation (Weakness)
o Impaired masticatory function  missing teeth and malocclusion.
2- Swallowing:
 Cleft palate in both the soft and hard palate:
o Fluid and food will regurgitate into the nasal cavity.
3- Esthetics:
 Cleft lip and/or in hard Palate :
o Cause a distorted abnormal facial appearance and look.
o Cleft in the soft wont effect the appearance though.
4- General Health:
Inefficient feeding, nutrition and mouth breathing Decrease in the general health.
5- Psychological trauma:
Congenital defects: Proper care and treatment
o Difficulty in adjusting to society.
 Normal attitude and intelligence
o Chang of attitude to Withdrawal or aggressiveness
o Feeling of inferiority and frustration.
6- Speech:
Complex mechanism between many organs including: Respiratory tract, tongue, teeth, lips, competent
soft and hard palate and an efficient plato-pharyngeal sphincter.
Phonetics: is learnt rather than an innate function but once learned, speech is developed
 Incompetent lips and/or cleft palate and/or inadequate plato-pharyngeal closure:
o Air needed for sound escapes through the nose rather than the oral cavity
 Thus Nasal speech are unclear
o Nasal Speech are (M , N , ing)
o Speech is more complicated with congenital defects than acquired, why?
 Children with congenital defects  they didn’t develop the correct speech pattern (speech is a
process learned) thus need speech therapy after correction of the defect to acquire the normal
patterns.
 While in acquired defects the speech pattern is already (almost always) acquired, thus by
correction the defect will not need any speech therapy.

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Speech Mechanism
1- Respiration:
o Exhalation produces a continuous stream of air.
o This air should have sufficient volume and pressure for speech.

2- Phonation:
o During air leaving the lungs and passing the trachea and larynx:
 Vocal Cords: modify the stream of air and forming Laryngeal sound (with characteristic sound and
intensity) thus producing voice.
 Soft palate and pharynx (Plato-pharyngeal sphincter): Controls the direction of air stream, either to:
 The oral cavity: production of all vowels and most letters except for the nasal
 The nasal Cavity: production of the nasal letters.

3- Resonance:
o The laryngeal sound is amplified through resonant chambers (Pharynx, oral cavity and nasal cavity)

4- Articulation:
o The laryngeal sound is modified (by the tongue, teeth , lips and palate) to give new sounds.
o The tongue change in position gives the sound special form and quality.

5- Neurologic Integration:
o The speech mechanism is coordinated by the central nervous system, thus any impairments
neurologically will affect the component the speech mechanism (soft palate, tongue or the entire speech
mechanism).

6- Audition:
o It’s the ability to receive sounds signals (hearing).
o This allows reception and interpretation of sound signals to help the speaker to monitor and control his
speech.

|Info|
- Production of correct sound depends on rapid and accurate positioning of the soft palate.
- When speaking (all except of the nasal letters “M,N,Ing”) the soft palate is raised to prevent air entering
the nasal cavity and directing it into the oral cavity.
- Nasal sounds are the only sounds made when the soft palate is lowered to allow the air to escape into
through the nasal cavity (Nose).

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|Habilitation of patients with clefts|
1. Pre-surgical Treatment:
o Time: from birth till surgical repair is done.
o Includes:
 Parent Psychological support by the social worker and nurse.
 Parent education (how to feed, proper nutrition for growth, care and clean the defect)
 Parent understanding and patience during feeding as its longer compared to normal infancts.
 Use of feeding devices, depends on the type of defect:
 Cleft Lip: feeding is easy and normal with slight milk leakage, this can be overcome by using
bottle with broad nipple to seal the defects and also they can be breast fed.

 Cleft Palate: feeding is difficult because of the loss of negative pressure


and generate maintain vacuum that’s needed for sucking, which leads to baby
fatigue and improper feeding. Use of squeezable bottle, soft nipple with cross cut,
long nipples (to be placed posterior to the defect) and feeding spoons (deep long
pointed tips).

2. Surgical Treatment:
o It should be done in the proper time when there are no contraindications for the surgery.
 Lips Repair:
 6-12 weeks after birth to help in feeding and improve appearance.
 Lip closure should be done without EXCESSIVE tension to establish good contour of the pre-maxillary area.
 Palatal Repair:
 1 year to 4 years of age depending on Childs general health, need for growth and the width of cleft.
 Early closure should be avoided to allow normal growth of the palate which helps narrowing the cleft.
 Its goal is to improve normal speech development, proper swallowing and breathing, minimize dento-
alveolar deformities and maintain proper maxillary growth.
 Treatment concerns closure of the cleft in many cases by lengthening of the palate.
 Treatment modalities:
 Palatoplasty: Relaxing incisions are made in the palatal mucosa. The mucosa is then
elevated and displaced medially towards the cleft palate.
 Push back operation: Anterior & lateral incisions are made The mucosa is pushed back &
sutured
 Pharyngeal flap operations.
 Bone grafts.

3. Orthodontic Treatment: appliances to correct the mal-aligned teeth if it’s required.


4. Prosthetic rehabilitation: rehabilitation of cleft palate usually requires some sort of prosthetic appliance.
o Indications:
 Failure and breakdown in surgical closure of the defect.
 Risky surgical closure.
 Rehabilitation of un-operated patients.
 Too Extensive cleft for surgical closure.
 In case of paralyzing the remaining soft palate.

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